Disseminated Intravascular

Coagulation (DIC)

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Table of Contents
 Preface
 Introduction
 Etiology of DIC
 Diagnosis of DIC
 Scoring systems for the diagnosis of DIC
 Differential diagnosis of DIC
 The coagulation cascade in DIC
 Normal coagulation cascade
 Pathophysiological changes in coagulation during DIC
 Management of DIC
 Prophylactic Anticoagulation
 Platelet Transfusion
 Plasma/Cryoprecipitate/Fibrinogen Concentrate Transfusion

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Disseminated Intravascular Coagulation (DIC)

Current Status 2020

Completed

Latest Update
First Edition

Ethics
Chair
Rik Gerritsen MD, PhD, FCCM, Intensive Care Department, Medical Centre
Leeuwarden, The Netherlands; Past Chair Ethics Section, European Society of
Intensive Care Medicine

Deputy
Christiane Hartog MD, Department for Anesthesiology and Intensive Care, Jena
University Hospital, Jena, Germany

Section Editor
Andrej Michalsen MD, Consultant in Intensive Care Medicine , Department of
Anaesthesiology and Critical Care, Tettnang Hospital, Tettnang, Germany

ELearning Committee
Chair
Kobus Preller Dr., Consultant, John Farman ICU, Cambridge University Hospitals
NHS Foundation Trust, Cambridge, UK

Deputy
Mo Al-Haddad MD, Consultant in Anaesthesia and Critical Care, Queen Elizabeth
University Hospital; Honorary Clinical Associate Professor University of Glasgow,
Glasgow UK

Project Manager
Estelle Pasquier , European Society of Intensive Care Medicine

First Edition 2020

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Module Authors
Nicole Juffermans MD, MD PhD Full professor of translational Intensive Care.
Department of Intensive Care., OLVG hospital, Amsterdam, the Netherlands and the
Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam
University Medical Center, Amsterdam, the Netherlands
Marcella Muller MD, PhD, Department of Intensive Care, Amsterdam University
Medical Center, Amsterdam, the Netherlands.

Module Reviewers
Beverly Hunt MD, Professor of Thrombosis & Haemostasis, Kings College London;
London, United Kingdom

Section Editor
Nathan D. Nielsen MD, M.Sc., FCCM, Associate Professor, Division of Pulmonary,
Critical Care and Sleep Medicine, University of New Mexico School of Medicine,
Albuquerque, United States; Editorial Board and Sepsis Section Editor, ESICM
Academy

CoBaTrICE Mapping Contributors

Cristina Santonocito MD, Dept. of Anesthesia and Intensive Care, IRCSS-ISMETT-
UPMC, Palermo, Italy
Victoria Anne Bennett MD, St George’s Hospital, London, United Kingdom

Co-Ordinating Editor
Nathan D. Nielsen MD, M.Sc., FCCM, Associate Professor, Division of Pulmonary,
Critical Care and Sleep Medicine, University of New Mexico School of Medicine,
Albuquerque, United States; Editorial Board and Sepsis Section Editor, ESICM
Academy

Executive Editor
Mo Al-Haddad MD, Consultant in Anaesthesia and Critical Care, Queen Elizabeth
University Hospital; Honorary Clinical Associate Professor University of Glasgow,
Glasgow UK

Intended Learning Outcomes

Disseminated Intravascular Coagulation (DIC)

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 1. Describe the clinical syndrome of disseminated intravascular coagulation (DIC)
2. Understand clinical consequences of DIC including the risk for bleeding and
thrombosis
3. Describe the pathophysiology of DIC
4. Recognize the patient at risk for DIC
5. Interprete laboratory findings in DIC
6. Determine the likelihood of DIC with the use of scoring systems
7. List differential diagnoses of DIC
8. Describe supportive care for DIC
9. Describe transfusion strategies for DIC
10. Describe current and future anticoagulant strategies for DIC
11. Understand the prognosis and clinical outcomes of DIC

eModule Information

Relevant competencies from CoBaTrICE

Disseminated Intravascular Coagulation (DIC)

2.1 Obtains a history and performs an accurate clinical examination

2.2 Undertakes timely and appropriate investigations
2.10 Integrates clinical findings with laboratory investigations to form a differential
diagnosis
3.1 Manages the care of the critically ill patient with specific acute medical
conditions
4.1 Prescribes drugs and therapies safely
5.10 Performs arterial catheterisation
6.1 Manages the pre- and post-operative care of the high risk surgical patient

Faculty Disclosures:
The authors of this module have not reported any disclosures.

Copyright©2017. European Society of Intensive Care Medicine. All rights reserved.

ISBN 978-92-9505-192-8 - Legal deposit D/2005/10.772/39

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1. Introduction
Disseminated intravascular coagulation (DIC) is a syndrome characterised by systemic
intravascular activation of coagulation, leading to the widespread deposition of fibrin, with
formation of widespread microvascular thrombosis. These microthrombi impair organ
perfusion and thus contribute to organ failure. During the coagulation process,
consumption of coagulation factors and aggregation of platelets occur resulting in reduced
levels of both procoagulant and anticoagulant clotting proteins. Therefore patients with
DIC may have both thromboembolic events and hemorrhage.

The Subcommittee on DIC of the International Society on Thrombosis and Haemostasis

has suggested the following definition for DIC: “An acquired syndrome characterized by
the intravascular activation of coagulation with loss of localization arising from different
causes. It can originate from and cause damage to the microvasculature and produce
organ dysfunction”.

Patients with DIC can have renal, hepatic and respiratory organ failure, as well as central
nervous system (CNS) and cutaneous/skin sequelae. Thromboembolic complications can
include both venous and arterial thrombosis. Venous embolism include deep venous
thrombosis and pulmonary embolism, which may be asymptomatic. Arterial thrombosis
includes acute limb ischemia and intraabdominal thromboses. Bleeding may present as
petechiae/ecchymoses (Figure 1) or oozing from wounds, sites of intravascular access,
mucosal surfaces and the gastrointestinal tract. Bleeding and thromboembolic events may
occur simultanously.

Figure 1: Skin lesions in DIC.

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2. Etiology of DIC

DIC never occurs by itself but is always secondary to an underlying disorder. DIC is
associated with a number of clinical conditions that generally involve activation of
systemic inflammation except for snake envenomations. These are listed in Table 1.

Table 1: Clinical conditions associated with

DIC

Severe infection and sepsis

Solid tumors
Hematologic malignancies
Obstetrical complications (HELLP, fluid
embolism, eclampsia)
Acute pancreatitis
Trauma
Severe transfusion reactions
Snake venom or other severe toxic
reactions
Heat stroke and hyperthermia

Severe infection and sepsis induce DIC through the release of proinflammatory cytokines,
such as TNF-α and intraleukin (IL)-6.

In sepsis, the cytokine release is induced by microbial membrane components which

cause a strong immune response. An increase in expression of tissue factor (TF) on
immune cells probably triggers a procoagulant response. Also, severe infection and
sepsis result in activation of the endothelium, which then also expresses tissue fator and
sheds high quantities of von Willeband factor, which initiates platelet aggregation. Both
Gram negative and Gram positive microorganisms have been associated with DIC, as
have viral and fungal pathogens.

Additionally, the cytokines released during sterile systemic inflammation, eg. in severe
acute pancreatitis, can lead to endothelial cell activation and coagulation dysfunction.

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Malignancies may be complicated by DIC through an increased expression of tissue
factor, microparticles and cancer specific procoagulants by tumor cells. Usually thrombotic
events appear more frequently than hemorrhage in DIC resulting from cancer.

Obstetric complications causing DIC consist of abruptio placentae, amniotic fluid

embolism and pre-eclampsia. In patients with abruptio placentae, the cause of the
activation of the coagulation system is most likely the leakage of TF from the placental
system into the maternal circulation. In the case of amniotic fluid embolism, the release of
procoagulant phosphatidylserine and tissue factor exposing extracellular vesicles may be
of importance in the development of DIC.

Trauma patients also develop heightened activation of the coagulation system and
accelerated fibrinolysis due to an inflammatory responde during acute injury. However,
whether DIC in trauma patients exists is a controversial topic, and some authorities have
preferred to differentiate the two entities, preferring the term Trauma Induced
Coagulopathy (TIC).

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3. Diagnosis of DIC
First, think whether DIC could be a possible complication of the patient’s presenting
condition. In other words, are there underlying risk factors that are associated with DIC?
Check the patient for signs of DIC and possible trombotic or bleeding complications. A
single laboratory marker to diagnose DIC is not available. DIC is a clinical-pathological
diagnosis, with a specific pattern of laboratory results, but unfortunately these coagulation
results can look the same as the coagulation defects associated with advanced liver
disease. It should also be taken into consideration that laboratory results may vary over
time as DIC is a dynamic condition. However, abnormal coagulation lab results combined
with a clinical presentation known to be linked to DIC supports the diagnosis.

Prothrombin time (PT), activated thromboplastin time (aPTT), fibrinogen and platelet
count provide useful information concerning the activation of coagulation and
consumption of procoagulant factors. Fibrin related markers (D-dimer, fibrin degradation
products) indicate the state of fibrinolysis. Typical abnormalities in DIC are prolonged PT,
prolonged aPTT, thrombocytopenia, elevated fibrin related markers and reduced
fibrinogen levels.

 Warning
Note that these abnormalities resemble that of liver disease.

 Task
Test your ability to diagnose DIC

A female of 30 yrs of age with a recent history of joint pains (not yet with an established
cause) presents to the Emergency Department with fatigue, muscle pain, fever and
confusion. She is in haemodynamic shock with low blood pressure and a lactate level of 6
mmol/L. Platelet count is 80 x 109 /L, PT is 14 sec, WBC is 14 x 109 /L, and there are
some fragments (schistocytes) in the smear. She is diagnosed with sepsis, resuscitated
and intubated. Broad spectrum antibiotics are administered. Renal replacement therapy is
started because of anuria. In the following hours, her shock stabilizes. The next morning,
lab results are repeated and it appears that platelet count has dropped further to 15 x
109 /L. This worries you and you re-think the cause of thrombocytopenia.

 what is your differential diagnosis of the thrombocytopenia?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

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
DIC, because sepsis is a risk factor and tests can be compatible with
consumption coagulopathy
Sepsis associated thrombocytopenia not meeting DIC criteria
(increased consumption and sequestration, decreased production)
consumption of platelets due to the RRT filter, because these filters
can remove platelets from the circulation and PT count can be
prolonged with anticoagulation for the RRT
Hemolytic Uremic Sydrome or Thrombocytopenic Thrombotic Purpura.
(Though the vast majority of TTP cases are idiopathic, there is some
association with lupus.).
Caveat: This degree of thrombocytopenia would be atypical for
HUS, and the degree of renal injury would be uncommon in
TTP.

 Which test needs to be done without delay?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 ADAMTS13. Activity levels of less then 10% indicate TTP, a disease

condition characterized by a deficiency of the enzyme ADAMTS13. The
purpose of ADAMTS13 is to cleave ultralarge von Willebrand Factor
multimers which easily stick to platelets due to a high affinity. If there is not
enough ADAMTS13 activity, these ultralarge vWF multimers form micro
thrombi, which disturb the microcirculation. Plasma exchange is life-saving
in TTP by removing inhibitory antibodies and ULVWF from the circulation,
in addition to replenishing ADAMTS13 enzyme activity. Therefore, this
treatment should be initiated immediately in case of TTP.
In sepsis, there is excessive endothelial secretion of vWF while
ADAMTS13 activity is reduced, resulting in a similar imbalance as seen in
TTP. Note also the similarities in coagulation adnormalities between DIC
and TTP (Table 2). However, ADAMTS13 levels in sepsis usually remain >
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20-30%, which can be used to differentiate DIC from TTP. In this case,
TTP is less likely because the degree of renal failure is usually not present
and HUS is less likely as this usually does not present with such low
platelet counts.

 Warning
Both HUS and TTP are medical emergencies, and immediate consultation should
be sought for the consideration of plasmapheresis if they are suspected.

Table 2: Similarities between TTP and DIC

Parameter TTP DIC

Cons
Cause Abs against A13
of A1
ADAMTS13
<10% 20-80
levels
VWF High High
PT NL Incre
Fibrinogen NL Decr
Platelets Low ++ Low
D-dimers Normal/increased Incre
Fragmentocytes ++ ++
Microthrombi ++ ++

3. 1. Scoring systems for the diagnosis of DIC

None of the mentioned laboratory values (platelet count, PT, APTT, fibrinogen and
fibrinogen degradation products) alone is specific enough to determine whether DIC is
present or not. Therefore, scoring systems have been developed to assess the diagnosis.
The International Society on Thrombosis and Haemostasis (ISTH) DIC score is widely
used to diagnose patients with overt DIC (ISTH score ≥5). The Japanese Association for

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Acute Medicine (JAAM) score is specifically designed for the acute onset of “sepsis-
induced coagulopathy”. This score may be useful to identify non-overt DIC (ISTH score 1-
4). This may be relevant, as recent studies suggest that anticoagulant therapy may
improve outcomes in septic patients with SIC or DIC, although the evidence is still not
robust. Thereby, it was felt important to identify sepsis patients with DIC at an earlier
stage in order to include them into trials investigating anticoagulant interventions. In 2017
the SIC score was developed, which resembles the JAAM score but is simplified (see
Table 3).

Also, whereas deranged PT and platelet count are associated with mortality in sepsis,
fibrinogen and D-dimer levels are not. In the JAAM definition, scoring for fibrinogen is
eliminated but scoring for systemic inflammatory response syndrome (SIRS) is added.

For the ISTH DIC score, 4 laboratory values (platelet count, PT, D-dimer or another fibrin
degradation marker, and fibrinogen) are required in order to score between 0 and 8
points. An ISTH DIC score ≥5 supports the diagnosis of DIC.
The JAAM DIC score consists of a systemic inflammatory response syndrome criteria
score (SIRS criteria) and 3 laboratory values (platelet count, PT and fibrin marker). A
JAAM DIC score of ≥ 4 supports the diagnosis of DIC. See Table 3.

Use of the different scoring systems:

Since no gold standard for DIC diagnosis exists, comparison of the scoring systems is
challenging.

In September 2019, updated guidelines from the ISTH proposed a 2 step scoring system,
with the SIC score to screen for SIC and if present, to further screen for DIC using the
ISTH criteria.

 Note
The SIC criteria have lower diagnostic specificity, and the clinical utlity of the SIC
scoring system has not yet been proven.

 Warning
These scoring systems should only be used IF risk factors for DIC are present!

Table 3: DIC scoring systems

ISTH DIC score JAAM DIC score SIC sco

Platelet
Platelet count /
t
 count
≥120 /µL
>
Platelet 80 -120/µL
0 0 150/
count or > 30%
points points µL
> 100/µL decrease
1 1 100-
50 - 100/ in 24h
point point 150/
µL < 80/µL or
2 3 µL
< 50/µL > 50%
points points <
decrease
100/
in 24h
µL

FDP/Ddimer
No 0 Fibrin/FDP 0
change points (mg/L) points
Moderate 2 < 10 1
rise points 10 - 25 point
Strong 3 ≥25 3
rise points points

PT 0 PT (value of PT-INR
prolongation points patient/normal 0 <1.2
≤ 3 sec 1 value) points 1.2-
3 - 6 sec point < 1.2 1 1.4
˃ 6 sec 2 ≥ 1.2 point >1.4
points

SOFA
score
Fibrinogen 0
0 SIRS criteria 0
level points
points 0-2 points
˃ 1g/L 1
1 ≥3 1
˂ 1g/L point
point point
≥2
points

 Task
Learn to appreciate the differences between the existing DIC scoring systems

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
Think how would these tests yield different estimates of the
incidence of DIC in a ICU patient population?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 The SIC and the JAAM score will both detect DIC associated with
severe infection more easily then the ISTH score because of the use of the
SIRS score in the JAAM score and the SOFA score in the SIC score. In
line with this, the JAAM score has a high sensitivity, but rather low
specificity for DIC. Vice versa, the ISTH DIC score displays a high
specificity, but a low sensitivity.

In text References

(Taylor FB et al. 2001; Iba et al. 2017; Gando et al. 2006)

 References
Taylor FB Jr, Toh CH, Hoots WK, Wada H, Levi M; Scientific Subcommittee on
Disseminated Intravascular Coagulation (DIC) of the International Society on
Thrombosis and Haemostasis (ISTH)., Towards definition, clinical and
laboratory criteria, and a scoring system for disseminated intravascular
coagulation., 2001, PMID:11816725
Iba T, Nisio MD, Levy JH, Kitamura N, Thachil J, New criteria for sepsis-
induced coagulopathy (SIC) following the revised sepsis definition: a
retrospective analysis of a nationwide survey., 2017, PMID:28963294
Gando S, Iba T, Eguchi Y, Ohtomo Y, Okamoto K, Koseki K, Mayumi T, Murata
A, Ikeda T, Ishikura H, Ueyama M, Ogura H, Kushimoto S, Saitoh D, Endo S,
Shimazaki S; Japanese Association for Acute Medicine Disseminated
Intravascular Coagulation (JAAM DIC) Stud, A multicenter, prospective
validation of disseminated intravascular coagulation diagnostic criteria for
critically ill patients: comparing current criteria., 2006, PMID:16521260

3. 2. Differential diagnosis of DIC

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The differential diagnosis relates to other conditions that can cause thrombocytopenia. In
the critically ill, thrombocytopenia most often is due to consumption, which is related to
the degree of illness. However, there are some specific conditions causing
thrombocytopenia that should not be missed, such as TTP, as already outlined. Consider
these conditions in your workup of thrombocytopenia (Table 4).

Table 4: Specific conditions to

consider in the Differential
Diagnosis of DIC

HITT
Thrombotic thrombocytopenic
purpura
Mechanical circulatory support
devices
Hemophagocytic lymphohistiosis
(HLH)
Hematological malignancies
Drug-induced
Alcohol-induced
Idiopathic thrombocytopenic
purpura (ITP)
Post transfusion purpura
Hypersplenism

 Task
Test your knowledge of the workup of a patient with suspected DIC


An elderly patient with pneumonia and sepsis is admitted to your
ICU. He is on mechanical ventilation, vasopressors and renal
replacement therapy, for which he receives continious unfractionated
heparin infusion. Complete blood count including platelets have been
low since admission. Think of a list of diagnostic tests you consider
to order in your workup of the thrombocytopenia.

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 COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER


DIC could be possible. Order lab tests to calculate the DIC score.
HITT could be possible if platelets drop following heparin or LMWH
administration. This seems unclear in this case. An ELISA to detect
anti platelelet factor 4 antibodies can be ordered but it often falsely
positive in septic patients (and acutely ill patients in general). If this is
positive, a functional platelet aggregation test can be done. In
functional tests, donor platelets are incubated with patient serum or
plasma and heparin. If HIT antibodies are present in the patietns
serum, this leads to the formation of a heparin–antibody–PF4 complex
that will bind to FcγRIIa receptors on the platelet and induce donor
platelets activation. Platelets then release serotonin in the
supernatant, which can be detected with the serotonin release assay
(SRA).
HLH is possible though not probable, as a clear risk factor is not
present in this case. A complete blood count, liver function tests,
levels of triglycerides, ferritin level, fibrinogen level can be ordered. If
HLH is suspected based on these test results, NK cell activity and
soluble CD25+ levels can be ordered additionally. Phagocytizing cells
can be seen in bone marrow aspirate or lymph node.
Hematologic malignancy is possible though not probable. An aspirate
can be considered as well as a leucocyte differentiation and LDH
levels.
For drug-induced thrombocytopenia, no specific lab tests exist.
ITP is an isolated disorder so not probable in this case. For ITP no
specific lab tests exist. A workup of causes of secondary ITP can be
considered, these include viral infections and lupus.

In text References

(Zarychanski and Houston 2017)

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 References
Zarychanski R, Houston DS, Assessing thrombocytopenia in the intensive care
unit: the past, present, and future., 2017, PMID:29222318

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4. The coagulation cascade in DIC

4. 1. Normal coagulation cascade

In order to understand the pathological activation of the coagulation cascade which
appears in DIC, the physiological coagulation cascade should be understood first. There
are three main pillars: the procoagulant system, the anticoagulant system and the
fibrinolytic system (Figure 2).

In response to trauma or inflammation-induced endothelial damage, Tissue Factor (TF) is

expressed. TF initiatites coagulation by activating Factor VII then Factor VIIa activates
FX. Activated factor X then induces the conversion from prothrombin into thrombin.
Thrombin formation is a key step as it initiates a series of reactions which amplifies the
procoagulant response including activating platelets, white blood cells and endothelium.
Thrombin also acts on fibrinogen to form fibrin, which together with activated platelets
form a stable clot.

The anticoagulant system is triggered by activated coagulation factors. The proteins that
compose this anticoagulant system primarily act by inactivating coagulation factors
(“procoagulants”). The main physiological anticoagulant proteins are protein C, protein S
and antithrombin (AT). In addition, tissue factor pathway inhibitor (TFPI) inhibits the early
stages of the coagulation cascade by blocking the TF-factor VII complex. Together, these
pathways form the anticoagulant system.

The fibrinolytic system is responsible for clot degradation, and results in the formation of
fibrin degradation products (FDP). The primary human fibrinolytic enzyme is plasmin,
which is formed from when plasminogen is activated by tissue plasminogen activator
(TPA). Inhibitors of fibrinolysis are thrombin activatable fibrinolysis inhibitor (TAFI) and
plasminogen activator inhibitor (PAI-1).

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 Figure 2:This scheme illustrates the coagulation pathways in black, the anti-
coagulant pathways in dashed and the fibrinolytic system in gray.From: Müller, M. C.
A. (2014). Coagulopathy and plasma transfusion in critically ill patients.

Figure 2: This scheme illustrates the coagulation pathways in black, the anti-coagulant
pathways in dashed and the fibrinolytic system in gray. Coagulation is initiated through
endothelial injury which leads to the formation of a tissue factor and factor VIIa complex.
Subsequently factor Xa and factor Va form a complex which leads to the transition of pro-
thrombin into thrombin. Thrombin plays a keyrole in an amplification loop and furthermore
initiates the formation of fibrin eventually leading to stable clot formation.
The anti-coagulant pathways consist of tissue factor pathway inhibitor (TFPI), activated
protein C (APC) and anti-thrombin (AT).
The fibrinolytic system is inhibited by thrombin activated fibrinolysis inhibitor (TAFI) and
plasminogen activator inhibitor 1 (PAI-1), both leading to inhibition of fibrinolysis.

4. 1. 1. Pathophysiological changes in coagulation during DIC

In DIC, all 3 pillars of the coagulation system are affected.

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Microorganisms and their components (such as lipopolysaccharides, described as
pathogen-associated molecular patterns or PAMPs), induce the expression of tissue
factor on monocytes and macrophages by binding to pattern-recognizing receptors.
Tissue factor, a major initiator of coagulation, and the tissue factor-initiated pathway
induce both prothrombotic and proinflammatory responses in part via protease-activated
receptors (PARs). Phosphatidylserine on cellular membranes can also active PARs.
Tissue factor and phosphatidylserine in extracellular vesicles also contribute to the
activation of coagulation. In sepsis induced coagulopathy (SIC or DIC, which are a
continuum), plasminogen activator inhibitor-1 (PAI-1) release in turn suppresses the
release of the key fibrinolytic enzyme tissue-plasminogen activator (t-PA). As a result, the
fibrinolytic system is suppressed by PAI-1, producing microcirculatory thrombosis, which
is the hallmark of SIC.

Additionally, in sepsis induced DIC substances that are released from damaged cells,
such as free-DNA, histones and high-mobility group box 1 protein (collectively termed
damage-associated molecular patterns, DAMPs) will contribute to thrombus formation.
Neutrophil extracellular traps (NETs) are mesh-like DNA fibers comprised of histones that
can prevent bacterial dissemination, but also damage the endothelium.

In non-sepsis induced DIC, fibrinolysis is more prominent. In hematologic disease related

DIC, TF initiates systemic coagulation that is insufficiently contained by the physiological
anticoagulant pathways and is amplified by impaired endogenous fibrinolysis.
Hematologic tumor cells and their derived vesicles can increase plasminogen activation.
Plasmin degrades fibrin and thereby increases the risk of bleeding.

 Task
Test your knowledge of the coagulation abnormalities in DIC.

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
This is a schematic representation of a blood vessel (Figure 3). Which
enhanced or inhibited processes in the 3 pillars (procoagulant,
anticogulant and fibrinolytic) lead to the disturbed coagulation
assays that underlie a diagnosis of DIC. Indicate in the figure whether
a process is enhanced or diminished in DIC by placing arrows up or
arrows down.

Figure 3:Blood vessel in which

coagulation and anticoagulant processes
are depicted. ESICM Academy 2020.

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER


The procoagulant pathways are excessively enhanced. TF expression and
vWF expression are increased, due to activation by tumor cells, vascular
endothelial cells and activated monocytes. TF activates coagulation factors
which are then consumed resulting in low coagulation factor levels. vWF
binds to platelets, also resulting in low platelet counts in the circulation.

The anti-coagulant pathways do not function properly as the protein C-based system is
impaired due to low concentrations of protein C. Protein S, which is essential for the
formation of activated protein C, is decreased as well. Additionally, cytokines lead to a
downregulation of expression of thrombomodulin, an important “brake” on thrombus
formation. Thereby, essential components in the formation of activated protein C are
compromised. Finally, antithrombin levels are reduced.

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The fibrinolytic process which breaks down clots is impaired. In particular, in sepsis-
induced DIC, there is an increase in PAI-1, resulting in the inhibition of tPA that in turn
leads to inhibited fibrinolysis. In malignancy-associated DIC, suppression of fibrinolysis is
less prominent.

The presence of DIC is probably not an “on or off” phenomenon but a continuum, ranging
from mild thrombocytopenia to overt DIC. Due to the pathophysiologic processes in the 3
pillars as described above resulting in the consumption of procoagulant proteins,
anticoagulant proteins and platelets in the formation of (micro)thrombi, the net decrement
in coagulant proteins means the individual with DIC is more prone to bleeding events.
However, it should be noted that both, thrombo-embolic events as well as hemorrhage
can occur, and can occur simultaneously. Typically, organ dysfunction often develops in
sepsis-associated DIC due to reduced tissue perfusion due to the predominance of
microthrombus formation, while in (non-septic) DIC with more prominent fibrinolysis,
systemic bleeding is a more common feature.

 Note
there are of course, exceptions to this rule, as there are pathogens that are known
to accelerate fibrinolysis, and many cases of non-sepsis DIC where thrombosis
predominates. There is no stereotypical presentation of DIC, whatever the root
causes may be.

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5. Management of DIC
Hallmark of treatment is management of the underlying disorder that is triggering DIC. If
that disorder is eliminated, DIC will resolve.

5. 1. Prophylactic Anticoagulation
In the non-hemorrhaging patient with DIC, the initiation of prophylactic anticoagulation
with low doses of unfractionated heparin (UFH) or low molecular weight heparins (LMWH)
should be strongly considered, and if prophylactic anticoagulation is already being
administered should not be stopped. This recommendation holds even if the patient is
already thrombocytopenic (though a “cut-off” platelet count is controversial).
Anticoagulation therapy is important because patients with DIC are fundamentally in a
procoagulant state and thus at risk for micro- and macro-thrombosis. In addition, in a
large retrospective study thromboprophylaxis reduced the development of
thrombocytopenia in DIC, presumably because it diminishes consumption of platelets by
slowing thrombus formation (Williamson et al, 2013). Besides pharmacological
thromboprophylaxis, mechanical thromboprophylaxis with pneumatic compression
devices can be considered.

It is also recommended to administer stress ulcer prophylaxis in DIC patients to reduce

bleeding (Williamson et al. 2013).

 References
Williamson DR, Albert M, Heels-Ansdell D, Arnold DM, Lauzier F, Zarychanski
R, Crowther M, Warkentin TE, Dodek P, Cade J, Lesur O, Lim W, Fowler R,
Lamontagne F, Langevin S, Freitag A, Muscedere J, Friedrich JO, Geerts W,
Burry L, Alhashemi J, Cook D, PRO, Thrombocytopenia in critically ill patients
receiving thromboprophylaxis: frequency, risk factors, and outcomes., 2013,
PMID:23788287

5. 2. Platelet Transfusion

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In the ICU, platelet transfusions are given prophylactically to correct a low platelet count
in the setting of a pending hemostatic challenge or to prevent “spontaneous”
haemorrhage – most current guidelines recommend <10 x 109 /L for the former though
the evidence for these thresholds are limited. In non-bleeding patients, DIC is NOT a
reason to transfuse platelets at a higher threshold than in patients without DIC. Also, the
presence of DIC alone is not a reason to transfuse platelets prior to an invasive
procedure. While these patients are at an overall higher risk of bleeding, it is unclear
whether prophylactic platelet transfusions reduce this risk.
In patients with DIC who are on anticoagulant medication, it is general practice to
maintain a somewhat higher trigger for prophylactic platelet transfusion than in non-
anticoagulated patients, although evidence to support this practice is absent.
As a general rule, platelet transfusions in DIC should be guided by the recommendations
applicable to all critically ill patients. Please refer to ICU transfusion guidelines (Vlaar et
al. 2020) for further details. Overall, a restrictive (conservative) threshold is
recommended. There is at least a theoretical concern for the acceleration of thrombus
formation with the transfusion of platelets or other procoagulant proteins (i.e.: in plasma or
cryoprecipitate).

 References
Vlaar AP, Oczkowski S, de Bruin S, Wijnberge M, Antonelli M, Aubron C, Aries
P, Duranteau J, Juffermans NP, Meier J, Murphy GJ, Abbasciano R, Muller M,
Shah A, Perner A, Rygaard S, Walsh TS, Guyatt G, Dionne JC, Cecconi M,
Transfusion strategies in non-bleeding critically ill adults: a clinical practice
guideline from the European Society of Intensive Care Medicine., 2020,
PMID:31912207

5. 3. Plasma/Cryoprecipitate/Fibrinogen Concentrate Transfusion

There is no indication for prophylactic plasma transfusion in DIC based elevated PT/PTT
levels alone, nor for prophylactic cryoprecipitate or fibrinogen concentrates for low
fibrinogen levels alone.
Transfusion support with plasma, cryoprecipitate or fibrinogen should only be reserved for
the haemorrhaging DIC patient, and should follow the current guidelines for the
management of the bleeding critically ill patient. (Of note, evidence that transfused
plasma reliably corrects any coagulation disorder is presently absent.)
The use of prothrombin complex concentrates (PCCs) have not been adequately
assessed in DIC, and as such, should only be used in DIC after very careful
consideration. As common consequence of PCC use is venous thrombosis, the risks
posed in DIC by their use may well outweigh potential benefits.
/
  Task
Review transfusion guidelines (Vlaar et al. 2020).

5. 3. 1. Therapeutic Anticoagulation Strategies

Patients with DIC and thromboembolism should be anticoagulated in the absence of
hemorrhage. Current guidelines suggest the use of unfractionated heparin (UFH). If there
is a strong contra-indication due to active bleeding, a caval vein filter should be placed in
case of thrombi in the lower extremities(Konstantinides et al. 2019).

In DIC patients without thromboembolic events, worldwide differences in the use of

anticoagulation medication exist, and the availability of these medications is very limited.

Antihrombin: There is a deficit in anticoagulant proteins in DIC, including a deficit of

antithrombin (AT). A large RCT on the efficacy of replenishing AT using high dose AT
in sepsis (Kienast et al. 2006) was negative overall, but did suggest a survival benefit
in the sub-group of patients with DIC. Current sepsis guidelines still recommend
against its use in septic patients, however.
Activated Protein C: Trials on the treatment of sepsis with human recombinant
activated Protein C (aPC) showed conflicting results on mortality and this drug was
taken off the market, though there have been subsequent post hoc analyses that
suggested benefits for patients with sepsis and DIC.
Thrombomodulin: Another option that was recently trialled is administration of
soluble thrombomodulin (sTM). sTM binds thrombin which serves to augment the
conversion of protein C to activated protein C. In addition, sTM inhibits inflammation
and organ injury caused by damage-associated molecular patterns. However, despite
initially promising study data from Japan, in a multinational RCT in sepsis-induced
coagulopathy the use of sTM did not reduce mortality (Vincent et al. 2019).

It merits noting that while European and North American guidelines recommend against
anthrombin and aPC use in sepsis and presently make no mention of sTM, the Japanese
guidelines differ, and in fact, recommend for the use of AT or sTM for the treatment of
sepsis-induced DIC.

 Task
Think about clinical management of a DIC patient

/

If anticoagulant treatment is started in a DIC patient with a deep vein
thrombosis, would this affect the platelet threshold at which you
transfuse platelets prophylactically in this patient?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 The risk of bleeding in this patient is increased due to the

consumptive coagulopathy and low platelet count due to DIC together with
the anticoagulant therapy. There are no data underlying a specific platelet
trigger in these patients. It may be prudent to adhere to a higher platelet
count as a trigger for platelet transfusion, such as 30-50 x 109 /L, though
there is little agreement even among experts on this point.


What are the risks and benefits of a platelet transfusion in a non-
bleeding DIC patient?

COMPLETE TASK THEN CLICK TO REVEAL THE ANSWER

 The benefit of platelet transfusion is that the risk of bleeding may

diminish. The risk of platelet transfusion is thought to be ‘fuelling the fire’,
meaning that platelet transfusions may contribute to ongoing consumption
of platelets with formation of microthrombi. The magnitude of these effects
are, however, unknown. Additionally, transfusion reactions of varying type
and severity are not uncommon with platelet transfusions.

In text References

(Dellinger 2006)

 References
/
Vlaar AP, Oczkowski S, de Bruin S, Wijnberge M, Antonelli M, Aubron C, Aries
P, Duranteau J, Juffermans NP, Meier J, Murphy GJ, Abbasciano R, Muller M,
Shah A, Perner A, Rygaard S, Walsh TS, Guyatt G, Dionne JC, Cecconi M,
Transfusion strategies in non-bleeding critically ill adults: a clinical practice
guideline from the European Society of Intensive Care Medicine., 2020,
PMID:31912207
Kienast J, Juers M, Wiedermann CJ, Hoffmann JN, Ostermann H, Strauss R,
Keinecke HO, Warren BL, Opal SM; KyberSept investigators., Treatment
effects of high-dose antithrombin without concomitant heparin in patients with
severe sepsis with or without disseminated intravascular coagulation., 2006,
PMID:16409457
Vincent JL, Francois B, Zabolotskikh I, Daga MK, Lascarrou JB, Kirov MY,
Pettilä V, Wittebole X, Meziani F, Mercier E, Lobo SM, Barie PS, Crowther M,
Esmon CT, Fareed J, Gando S, Gorelick KJ, Levi M, Mira JP, Opal SM, Parrillo
J, Russell JA, Saito H, Tsur, Effect of a Recombinant Human Soluble
Thrombomodulin on Mortality in Patients With Sepsis-Associated
Coagulopathy: The SCARLET Randomized Clinical Trial., 2019,
PMID:31104069
Dellinger RP, Recombinant activated protein C: the key is clinical assessment
of risk of death, not subset analysis., 2006, PMID:16542472
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP,
Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM,
Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P,
Pruszczyk P, Righini M, Torbicki A, Van Bell, ESC Guidelines for the diagnosis
and management of acute pulmonary embolism developed in collaboration
with the European Respiratory Society (ERS)., 2019, PMID:31504429

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